NRNP 6560 MIDTERM EXAM STUDY MATERIAL WITH ALL CORRECT ANSWERS 2024 UPDATED AND GRADED 100, Exams of Nursing

Download NRNP 6560 MIDTERM EXAM STUDY MATERIAL WITH ALL CORRECT ANSWERS 2024 UPDATED AND GRADED 100 and more Exams Nursing in PDF only on Docsity! NRNP 6560 MIDTERM EXAM STUDY MATERIAL WITH ALL CORRECT ANSWERS 2024 UPDATED AND GRADED 100% PASS Surgery risk classes - Solution Class 1: benefits outweigh risk, should be done Class 2a: reasonable to perform Class 2b: should be considered Class 3: rarely appropriate General rules for surgery: testing - Solution ECG before surgery only if coronary disease, except when low risk surgery Stress test not indicated before surgery Do not do prophylactic coronary revascularization Meds before surgery - Solution - Diabetic agents: Use insulin therapy to maintain glycemic goals(iii) Discontinue biguanides, alpha glucosidase inhibitors, thiazolidinediones, sulfonylureas, and GLP-1 agonists - Do not start aspirin before surgery - Stop Warfarin 5 days before surgery. May be bridged with Lovenox. - Do not stop statin before surgery - Do not start beta-blocker on day of surgery, but may continue Assessment of surgical risk - Solution - Unstable cardiac condition (recent MI, active angina, active HF, uncontrolled HTN, severe valvular disease), concern with CAD, CHF. arrhythmia, CVD - patient stable or unstable? - urgency of the procedure (oncology will be time sensitive) - risk of procedure - nutritional status - immune competence - determine functional capacity (need to be more than 4 METS, more than 10 METs makes low risk) Low risk surgeries - Solution catarcts breast biopsy cystoscopy, vasectomy laporascopic procedures Plastic surgery intermediate risk surgeries - Solution Head/ neck surgery thyroidectomy Intraperitoneal Prostate Laminectomy Hip/ knee Hysterectomy cholecystectomy nephrectomy non majot intrathoracic High risk surgeries - Solution aortic/ cabg transplants spinal reconstruction peripheral vascular surgery Lee's revised cardiac risk index - Solution 6 points: High risk surgery = 1 CAD = 1 CHF = 1 Cerebrovascular disease = 1 DM 1 on insulin = 1 Creat greater than 2 = 1 1 = low risk 2 = moderate risk 3 = high risk SCIP pre-operative infection measures - Solution - Prophylactic antibiotics should be received within 1 h prior to surgical incision - be selected for activity against the most probable antimicrobial contaminants - be discontinued within 24 h after the surgery end-time Postoperative infection reduction methods - Solution - pre-op hair removal (clippers) - synovial fluid: yellow, thick with elevated WBC up to 100.000 Felty's syndrome - Solution rheumatoid arthritis, splenomegaly, neutropenia Rheumatoid arthritis treatment - Solution - early treatment better than stepwise - early referral rheumatologist - disease-modifying anti-rheumatic drugs (DMARDs): - methotrexate ( no alcohol, monitor renal and liver, give with folic acid) - cyclosporine - Gold preparations (can cause thrombocytopenia) - Hydroxychloroquine: antimalarial drug (may cause visual changes, monitor) - sulfasalazine, moderate RA - Leflunomide, moderate to severe RA - Etanercept - monitor liver function with DMARDs - screen for TB (skin test) and Hep B - surgery: joint debridement, joint replacement Gout: what, who - Solution Inflammatory disorder in response to high uric acid production/ levels in blood and synovial fluid causing crystallization which causes inflammation (Type A and Mediterranean) - impaired renal function which causes excess uric acid - foods high in purine, such as dairy, red meat, shellfish, beer Gout findings, diagnostics - Solution - acute painful joint, often great toe (warm, swollen) - pain at night - flank pain because of renal calculi - fever - leukocytosis - elevated erythrocyte sedimentation rate - tophi (bump under skin) on ear - limited joint motion - elevated serum uric acid (greater than 7mg/dl) - urate crystals seen with joint aspiration - xr: joint erosion and renal stones Gout treatment - Solution - NSAIDS: naproxen, ondomethacin, sulindac - Colchicine for those who do not tolerate NSAIDS (caution with renal impairment). Also for prophylaxis - Corticosteroids, if NSAIDS and colchicine not tolerated - 24hr urine for uric acid - Allopurinol after flare is over (100mg PO daily) - Biological modifiers of disease (BMD): Pegloticase. Not for asymptomatic. Treat with prophylaxis first. Monitor serum uric acid ANA. Tests in rheumatic disease: what, normal level, abnormal with. - Solution Antinuclear antibody (ANA). Normal: Titer 1.32 POsitive with: Sjogren's (SS), SLE (lupus), C4 Complement. Tests in rheumatic disease: what, normal level, abnormal with. - Solution Determines hemolytic activity which speaks to level of inflammatory response Normal: men: 12-72. Women: 13-75 mg/dl Increased with: inflammatory disease Decreased with: RA, lupus, SS The radioallergosorbent test (RAST). Tests in rheumatic disease: what, normal level, abnormal with. - Solution measures presence/ increase antigen IgE normal: 0.01 - 0.04 mg/dl Increased with allergic reaction Erythrocyte sedimentation rate (ESR). Tests in rheumatic disease: what, normal level, abnormal with. - Solution rate at which RBC settle out of unclotted blood in 1 hr Normal: men: 0-7mm/hr, women: 0 - 25 mm/hr Increased with inflammation CRP. Tests in rheumatic disease: what, normal level, abnormal with. - Solution C-reactive protein, a non-specific antigen antibody Normal: trace to 6mg/ml Increased with infection and inflammation, RA. Decreased with succesfull RA treatment RF. Tests in rheumatic disease: what, normal level, abnormal with. - Solution Rheumatoid factor. antibody against IgG. Positive RF in most people with RA Corticosteroids and arthritis: what does it do and adverse effects - Solution Not for maintenance Use lowest dose Suppresses flares nausea, hyperglycemia, weight gain, adrenal insufficiency, mask infections NSAIDS and arthritis: what and adverse effects - Solution analgesic and anti-inflammatory give PPI concurrently to prevent GI complication Headache, htn, fluid retention, n/v, ulcers/ bleeding, abnormal liver function tests, rash, renal insufficiency Celebrex and Arthritis - Solution Analgesic and anti-inflammatory Fewer ulcers than with other NSAIDS Not recommended in renal or liver failure Screen for sulfa allergy May cause cardiovascular thrombotic event May cause GI adverse event subluxation: what, cause - Solution partial dislocation of a joint. Common sites: shoulder, elbow, wrist, hip, knee, patella, ankle, spine trauma, blunt force neuromuscular disease inflammatory joint disease, RA Loose ligaments Ehlers-Dantos syndrome (loose ligaments and overflexible joints- congenital) Findings and diagnostics subluxation - Solution Pain over affected area previous subluxation swelling around joints loss of ROM Ligaments/ sprain: pain on palpation and ROM, decreased ROM with moderate swelling, Lachman's test (hypermobile joint is positive sign) Strain/ muscle or tendon: swelling, decreased/ absent ROM, pain/ guarding Cartilage: swelling, click during McMurray's test (would indicate meniscus tear), pain/ guarding Bursa: swelling with boggy feeling, erythema over bursa, decreased ROM Skin: abrasion, laceration, puncture Soft tissue injury findings and diagnostics - Solution WBC increased, especially with bursitis Hgb decreased with massive hematoma Synovial fluid aspiration: WBC with inflammation, RBC with bleeding into joint, crystals with gout Xr will reveal swelling MRI (knee/ shoulder) location and degree of injury Soft tissue injury management - Solution PRICE (protection, rest, ice, compression, elevation) possible immobilization surgery, if rupture, grade III ligaments sprain, septic bursa, wound closure PT NSAIDS Muscle relaxant Opioids - short term Broad spectrum ab's (cephalexin, cefazolin) Fracture Classification - Gustillo - Solution - Closed - Open: Type 1: wound smaller than 1cm Type 2: wound larger than 1cm, moderate contamination Type 3: high degree of contamination, severe fracture instability, soft tissue damage. T3A: soft tissue coverage adequate, T3B: extensive injury soft tissue, exposed bone, T3C: open fracture with arterial injury - Incomplete or complete - stress - traumatic/ pathologic - displaced/ non-displaced Type of fracture lines - Solution Transverse Spiral Oblique Comminuted Logtitudinal butterfly segmental impacted Salter-Harris Fracture Classification - Solution Concerns growth plate S: straight across growth plate A: Above growth plate L: BeLow growth plate T: Through growth plate R: ERaser of growth plate (Rammed) Cause of fractures - Solution Trauma, tumor, osteoporosis, drugs (prednisone), nutritional deficiency (Vit D), neuromuscular disorders Findings and diagnostics of fractures - Solution Pain History of traumatic event Neuromuscular dystrophy: headache (autonomic dysreflexia) Deformity of limp Diminished/ absent pulses ecchymosis and swelling xr, always order anteroposterior and lateral CT scan for pelvic and spinal fractures MRI for suspected spinal cord injury Mortise view (leg inward) for ankle to check talus bone oblique films for humerus, femur, ankle DEXA scan to determine degree of osteoporosis Acute Fractures Management - Solution - ABC care (Airway, breathing, circulation), musculoskeletal second survey - fluid resuscitation - early reduction of fracture - cover open wounds - surgical irrigation and debridement for open fracture - Ab's: Cefazolin for gram pos. Clindamycin for tetani infection - pain: opioids - tetanus shot of unknown - calcium upon discharge for osteoporosis - cement injection in bone with vertrebroplasty Fractures: Reduction - Solution - Orthopedic surgeon referral - buddy-tape toe fracture for immobilization - radius/ ulna: splint with ace-wrap, unless open - post reduction xr - check neurovascular function pre and post reduction - intramedullary rodding for closed femoral and tibial fracture - external fixation for open fracture Compartment syndrome: what, who - Solution Increased pressure in tissue limits the circulation and function of the contents within that space (compartment: bone, blood vessel, nerves, muscle, soft tissue). Most often in arms and legs (most compartments), also abdomen Men under age 35 stemming from fracture of tibia stemming from splint, cast, scar increased swelling due to hemorrhage, coagulation disorder, infiltrated iv site, trauma/ surgery, burn, bite Compartment syndrome finding and diagnostics - Solution pain out of proportion to injury hx of trauma paresthesia heaviness in affected extremity Six P's: Pain on passive stretch Paresthesia Paralysis of affected limb (late finding) Pulses, bounding first then pulseless later Pallor of affected limb - Atrophy of muscles - limp - possible straight leg raise test/ radiculopathy - limited rom spine - xr anteroposterior and lateral of spine - CT with and without dye: detects bony defects - MRI: detects soft tissue defects - myelogram - EMG (tests nerve innervation) Herniated disk L4 root finding (disk between L3 and L4) - Solution - quadriceps weak, difficulty extending quadriceps (have pt squat and rise) - pain and numbness radiating into medial malleous - diminished/ absent knee jerk Herniated disk L5 root finding (disk between L4 and L5) - Solution - dorsiflexion of great toe and foot weak (have pt walk on heels of feet) - pain and numbness into lateral calf and between first toe web space Herniated disk S1 root finding (disk between L5 and S1) - Solution - weakness of plantar flexion of great toe and foot (have pt walk on toes) - pain along buttock, lateral leg and lateral aspect of foot and posterior calf - diminished achilles calf Herniated disk management - Solution Non surgical: - functional bracing - rest - PT for muscle strengthening - heat/ ice alternate - weight loss - transcutaneous electrical nerve stimulator - NSAIDS - antispasmodic - Narcotics for short-term use - epidural steroid injection Surgical: - Laparoscopic diskectomy - hemilaminectomy - total disk replacement arthroplasty HIV and age - Solution - Can live beyond 50 years, but survival decreases after 45 yrs, unless tested. - Antiretroviral meds are approved for younger than 50yrs, so older pt's need close monitoring HIV etiology - Solution Africa/ Asia: heterosexually acquired Western nations: men who have sex with men, iv drug user, congenital spread Pathophysiology of HIV - Solution - HIV infects cells with CD4 receptor (macrophages, Tcells). Acute infection (high viral load) then latent (lower viral load). When CD4 is less than 200 AIDS and viral load increases again, this immunodeficiency - HIV is chronic and prgressive: HIV - acute retroviral syndrome, symptoms - Solution fever, chills fatigue diffuse erythematous rash HIV test may be negative, based on how long since infection HIV viral load increased, CD4 within normal range HIV - latent phase - Solution - asymptomatic - may have persistent lymphadenopathy - HIV load and CD4 load variable (ultimately HIV load high, CD4 low) Symptomatic HIV disease - Solution Symptoms: fever, chills, diarrhea, weight loss - infections: candidiasis/ thrush (oral, mucocutaneous, vaginal), shingles (herpes zoster), frequent bacterial infections AIDS, definition and diagnosis - Solution acquired immune deficiency syndrome CD4 low, below 500 and infection with opportunistic organism Or: CD4 below 200 Common oppertunistic organism in AIDS - Solution Pneumocystis jiroveci Cryptosporidium Candida albicans Advanced HIV infection: definition, symptoms, prognosis - Solution CD4 below 50 Wasting, fevers, fatigue Poor HIV serologic testing - Solution - ELISA: test for antibodies, requires seroconversion (neg to pos) which happens 3wks to 6mo after infection - Rapid test: fast but not as sensitive as ELISA - Confirmatory HIV test: Western blot test (HIV antibody test), used after pos with ELISA HIV prevention - Solution - Condoms - Male circumcision - Pre-exposure prophylaxis (PrEP), for MSM sexually active men, adult iv drug users, women with HIV pos partner who try to conceive. Give Tenofir with Emtricitabine - Post exopsure prophylaxis (PEP), 28 day course of 3 drugs, emtricitabine, tenofovir, raltegravir LABS for HIV + people - Solution CD4 count (viral load) HIV RNA level WBC (neutropenia, lymphopenia) CBC (anemia) LFT's ( ^liver enzymes)/ Hep A, B, C screening TB test Resistance testing for RX\Syphilis testing Pap smear xr chest Initiation of Antiretroviral therapy (ART) - Solution - Start for all asymptomatic HIV infected patients to reduce viral load and risk of disease progression. Also for HIV+ peope to for prevention of transmission. - Start for every symptomatic patient regardless of CD4count or viral load trapping of antibodies in capillary and visceral structures, destructing host cells. Exacerbations/ remissions systemic lupus erythematosus (SLE), incidence - Solution - drug-induced; hydralazine, methyldopa, quinidine, chlorpramazine, isoniazid - triggers for malfunctioning of T and B cellsL sex hormones, UV radiation, infection, stress - mostly women - mostly African-American - familial risk systemic lupus erythematosus (SLE), findings - Solution - joint symptoms without synovitis - fever, malaise, weight loss, anorexia - skin lesions - oral and nasal ulcers - ocular changes - HF; myovcarditis, pericarditis, cardiac arrhythmia's, htn - pleural effusions, pneumonia, pleurisy - CKD - abd pain - cognitive impairment, depression, stroke, seizures - serum antinuclear antibody present in all pt's but not specific - no specific diagnostic test - may be abnormal: anemia, leukopenia, thrombocytopenia, positive coombs, proteinuria, hematuria, false/ pos for syphilis systemic lupus erythematosus (SLE), treatment - Solution - supportive, not curative - sunscreen (photosensitivity) - corticosteroid cream - NSAIDS for joint symptoms - Hydroxycloroquine, takes 6mo till effect is seen - Prednisone - hospital for worsening RF, or severe infections - Calcium and Vit D when on longterm corticosteroids - Warfarin to achieve INR for 2-3 Cytotoxic drugs for life-threatening manifestations (lupus nephritis) types of donors - Solution Deceased: brain dead or non-heart beating Living: related (family), unrelated (friend), paired exchange, altruistic Contraindications to receive organs - Solution - malignancy - infection - smoker, drugs - noncompliance - acquired immune deficiency syndrome - HIV - morbid obesity Immune response - Solution - from B cells or T cells, that react and form antibodies - Human leukocyte antigens (HLA) recognize self and non-self. Panel reactive antibody (PRA) measures preformed HLA and indicates a good match when elevated. Crossmatching required before kidney, but post heart, lung, liver, pancreas transplant Organ rejection, types, - Solution Allograft rejection: recipient's immune system recognizes graft as non-self and causes local and systemic immune response Hyperacute: within minutes, rapid tissue necrosis Accelerated acute: 1-5 days post op, difficult to treat Acute: within first few months, can be treated mostly chronic: occurs slowly and leads to eventual graft loss, no treatment Organ rejection diagnosis, treatment - Solution Diagnosis gold standard: biopsy of graft. Symptoms mostly failure of the organ (renal failure, liver failure, pulm effusions/ infiltrate, etc. Also, graft tenderness) Treatment: high dose corticosteroids, optimizing immunosuppressant regimen, antilymphocytic therapy immunosuppression: what and general considerations - Solution Pharmacological manipulation of immune system to prevent/ suppress rejection. - Started before or after transplant for up to 2 wks to delay first rejection episode - maintenance for live of graft - caution with conversion between generic and brand forms of cyclosporine - Calcineurin inhibitors metabolized via cytochrome P450 enzyme, so may alter other drig concentrations - avoid grapefruit juice when on calcineurin inhibitors (may cause increase) Common medical complications in organ transplantation - Solution HTN Calcium channel blockers often used to treat. Usually multiple agents necessary. Avoid hypotension in kidney recipient. Posttransplant diabetes mellitus May be related to corticosteroids. Increases risk for graft loss. Tight glycemic control indicated. Renal insufficiency Nephrotoxicity from meds (Calcineurin inhibitors). Treatment: reduce Calcineurin inhibitors dose, limit other nephrotoxic meds Hyperlipidemia From effect of immunosuppresive meds on lipid levels (mostly from sirolimus). Optimize pharm cholesterol management Bone disease Osteoporosis common, related to corticosteroid. Baseline and annual bone scan necessary. Minimze corticosteroid use, give calcium Malignancy Increased incidence of lymphoma, skin ca, Kaposi's sarcoma. Related to Epstein-Barr and high doses of cyclosporine and tacrolimus. Treat: minimize immunosuppression, start radiation. Poor prognosis. Calcineurin inhibitors: which, indication, adverse effects - Solution Tacrolimus Cyclosporine Prophylaxis of rejection T: tremor, renal dysfunction, hyperglycemia Liver transplantation, incidence and complications - Solution Chronic hepatitis, alcoholic liver disease, hepatocellular carcinoma, ESLD Surgical: Hepatic Artery Thrombosis. Any time post transplant causing bile leaks, graft necrosis, abscess. Diagnosis with US or CT. Treat with thrombectomy, regrafting Portal vein thrombosis Portal htn and esophageal varices Biliary leaks treat with perc or surgical drainage Graft dysfunction Primary: within first week Elevated LFT, acidosis, encephalopathy. Poor prognosis Rejection Infection Biliary cast syndrome (bile duct strictyure and clogging) Recurrence of disease Lung transplantation, incidence and complications - Solution Pulm HTN, CF, COPD, sarcoidosis. When life expectancy is 24-36mo. Surgical: Bronchial anastomotic complications: ischemia and necrosis of anastomosis. Place stent with bronch. Bleeding Ischemia/ reperfusion therapy 72 hrs post op. Major cause of death. Causes alveolar damage, pulm edema, hypoexemia. Place on vent. Sepsis Bronchiolitis obliterans syndrome From chronic rejection causing exertional dysonea and cough with decreased FEV1. Treat with high-dose corticosteroid. Rejection. Heart transplantation, incidence and complications - Solution cardiomyopathy, cardiac tumor, congenital heart defect, valvular disease Bleeding Rejection Cardiac allograft vasculopathy Leading cause of death. Accelerated form of CAD causing HF, ventricular arrythmia's, death. Denervation altered response to drugs, little response to digoxin and atropine Pancreas transplantation, incidence and complications - Solution Diabetes Mellitus 1 Surgical: Anastomotic leaks. Within first few mo. Abd pain and increased amylase. Surgical correction. Bleeding Causing hematuria, cystitis, urethritis, urine leak, metabolic acidosis, intra- abd abscess Pancreatitis Mild posttransplantation Will resolve spontaneously Sepsis Leading cause of death. Peritonitis Rejection Intestinal transplantation, incidence and complications - Solution Necrotizing enterocolitis, Chrohn's, stenosis of small bowel Surgical: Bleeding Bowel obstruction Ascites Perforation Biliary leaks Hypermotility In early posttransplant phase. Give antidiarrheals and fiber. Rejection Infection Hepatitis - Solution Inflammation of the liver, caused by Hep A, C, D, E as RNA and B as DNA Hepatitis A: what, etiology, findings, management - Solution Viral Hepatitis Spread by fecal-oral route. Poor sanitation. -Pos Immunoglobulin IgM anti-HAV - first week of disease, disappears after 3 - 6 mo. So pos when infected in last 6mo. Neg: no infect in last 12mo - ALT AST elevated - Pos IgG anti-HAV. Means previous exposure and immunity. If neg: no infection. - Bedrest till jaundice resolves, no lifting - High caloric diet, small frequent meals. Low protein, no fatty foods, high carb - no alcohol - hospital for encephalopathy or coagulopathy - antiemetics Vaccine: Hep A for children 1 year and people increased risk IV drug use sex men with men underdeveloped countries piercing/ tattoo Viral Hepatitis Symptoms/ diagnostics - Solution - Prodromal phase: malaise, arthralgia, upper resp symptoms, anorexia, n/v, diarrhea/ constipation, skin rashes, aversion to smoking (HBV), mild upper quadrant abd pain - Icteric phase: jaundice, no icterus, dark urine Physical: tender hepatomegaly, splenomegaly, cervical lymphadenopathy, rash (HBV), arthritis Diagnostics: WBC wnl or low Proteinuria Bilirubinuria ALT and AST elevated (greater than 500) Bilirubin elevated PT normal, if elevated: severe liver damage Autoimmune hepatitis: what, etiology, findings, management - Solution unresolving inflammation of liver with unknown cause More women than men - Abnormal serum globulins and presence of autoantibodies - Abnormal serum aminotransferases Prednisone monotherapy, induction and maintenance Prednisone with azathioprine, induction and maintenance May need liver transplant Diagnose autoimmune hepatitis - Solution Young women ALT higher than AST Will have anti smooth muscle antibody nonalcoholic steatohepatitis (NASH): what, etiology, findings, management - Solution Nonalcoholic fatty liver disease. Hepatic fat with inflammation without causes such as alcoholism or medication. No fibrosis (scarring of liver which can lead to cirrhosis). Obesity, DM, dyslipidemia risk factors Serum aminotransferase and CT/ MRI for initial screening Liver biopsy: hepatic inflammation or fibrosis? - Lifestyle changes: weight loss, exercises - Medications: Vit E (for non DM) - Bariatric surgery - May require transplant, if liver cirrhosis Diagnose NASH - Solution Obese people! ALT higher than AST Diagnosis of exclusion NAFLD (non-alcoholic fatty liver disease) fibrosis score - Solution less than 1.455: no fibrosis greater than 0.676: advanced fibrosis Primary biliary cirrhosis: what, etiology, findings, management - Solution Autoimmune disease From environment and genetics LFT's up Immunoglobulins present Pos Antimitochondrial antibodies Hyperbilirubinemia Ursodiol May require liver transplant Diagnosing primary biliary cirrhosis - Solution Common in middle aged women, causes fatigue and itching. Tired, itching woman Positive anti mitochondrial antibodies (liver biopsy) Alk phos elevated Portal granumolas (intrahepatic biliary ducts destruction) Increased cholesterol Bilirubin up late in disease Diagnosing Primary sclerosing cholangitis - Solution Intra en extra hepatic flow is blocked. Associated with ulcerative colitis Fibrosis of biliary duct seen on cholangiography) Alk Phos elevated Total bili elevated Primary sclerosing cholangitis: what, etiology, findings, management - Solution Chronic cholestatic (bileflow from liver is blocked) liver disease: inflammation and fibrosis of bile ducts in and out of liver, bile strictures. Often leads to cirrhosis. Often asymptomatic Often also have Crohn's or ulcerative colitis Gold standard: endoscopic cholangiopancreatography or MRI Open biliary obstruction with endoscopy May need liver transplant Hereditary Hemochromatosis: what, etiology, findings, management - Solution Inappropriate absorption of dietary iron, that can lead to cirrhosis, hepatocellular ca, diabetes, heart disease Caucasian/ Northern European/ Celtic Elevated iron ferritin Hemochromatosis gene detection Iron overload? Then phlebotomy with goal of ferritin 50 - 100 No Vit C and iron HELLP syndrome: what, signs, treatment - Solution hemolysis, elevated liver enzymes, low platelets Triad: jaundice, coagulopathy, low platelets Steatosis (fatty liver) Intrahepatic hemorrhage Deliver baby Scoring systems for acute liver failure - Solution King's College Criteria: indicator for poor prognosis - Acetaminophen induced considered for transplant if: PH less than 7.3, encephalopatic, INR greater than 6.5, creat greater than 3.4 - Non acetaminophen: liver transplant if INR greater than 6.5, encephalopathy, younger than 10 or older than 40, jaundice, bilirubin high, unfavorable etiology (Wilson's). Model for End-Stage Liver Disease (MELD): to determine severity of liver disease, based on bilirubin, INR, and creat. Complications from liver disease with treatment - Solution - Cardiac: portal HTN, arrythmia's, edema - Dermatologic: jaundice, pruritis. Cholestyramine or Colestipol for pruritis - Fluid/ electrolytes: ascites, hypokalemia, hyponatremia, hypernatremia, hypoglycemia. D10 for hypoglycemia. Water restriction for hyponatremia. Replace K. Low sodium diet, fluid restriction, and diuretics, potential paracentesis (give albumin) for ascites. Give Bicarb for severe acidosis. - GI: GI bleeding, abd pain, varices, n/v - Neuro: hepatic encephalopathy. Give lactulose. Limit protein. Rifaximin BID if no lactulose tolerated. - Resp: Hyperventilation, hypoxemia Mech ventilation possible. - Renal: RF, oliguria, hyponatremia, hypotension. May need dialysis. Liver disease labs - Solution - elevated bili - decreased albumin - prolonged PT. Give Vit K subq for PT greater than 14 and INR greater than 2 - ALT and AST elevated - ammonia elevated Liver labs - Solution Cytotoxic: AST (made in liver): marker for hepatic inflammation. Low specificity for the liver. Will go up in recent liver injury. Does not indicate liver function. ALT: marker for hepatic inflammation. High specificity fir the liver. Will go up in recent liver injury. Does not indicate liver function. Albumin (made in liver): low means chronic liver injury PT: prothrombin time. Reliable and most sensitive for acute and chronic liver disease. Clotting time. INR will be elevated (PT usually tenfold). Low Vit K and coumadin can also increase prothrombin time. Cholecystitis: what, etiology - Solution Inflammation of galbladder, acute or chronic. Often with gallstones (cholelithiasis). - Gallstones: obstruct cystic duct which causes inflammation behind it. From cholesterol. - Acalculous cholecystitis: rare. With unexplained fever or after multiple trauma and poor oral intake -bacteria - cancer - risk factors: obesity, pregnanvy, sedentary lifestyle, low fiber diet, female, older age, high cholesterol mild: no organ dysfunction moderate: leukocytosis, complaints longer than 72 hours, local inflammation Severe: organ dysfunction Cholecystitis: findings/ diagnostics - Solution - asymptomatic, devloping into bloating/ abd pain - biliary colic: intense epigastric pain radiating to shoulder/ back - N/V - anorexia - elevated temp - pos Murphy's (pain on inspiration with fingers under right rib cage) - palbable galbladder - jaundice - right upper quadrant pain, fever, leukocytosis, guarding with severe inflammation - leulocytosis - elevated bili - Increased alanine transaminase, aspartate transaminase, lactate dehydrogenase, alkaline phosphatase - elevated amylase - ecg and xr chest to rule out mi or pneumonia - US: best study for diagnosiing gallstones - ERCP: assess biliary and pancreatic ducts - Graded by severity: Cholecystitis: management - Solution NPO IV fluids Pain control (NSAIDS) AB's iv (third gen cephalosporin, zosyn, merrem) Surgery: Cholecystectomy ERCP for stones in bileduct Ursodiol for small stones (smaller than 2cm) Large bile duct obstruction - Solution Pain/ fever Alk phos elevated Total bili elevated - Elevated Hgb and Hct - metabolic acidosis - electrolyte imbalances - supine and upright abd xr: air-fluid levels ladderlike, free air reqiures immediate surgery - US abd: dilated loops of bowel filled with fluids. Specific but not often used. - Can use barium but CT better (also better than xr) Small bowel obstruction: management - Solution - NPO - Fluid and electrolyte replacement - NG to LIS - bld. cult, CBC, CMP, ABG, lactate - AB's for suspicion of perforation - surgery for complete obstruction or partial that doesn't improve Large bowel obstruction: what, etiology - Solution Blockage in large bowel that prevents food from passing through which causes blood supply cut off which can cause a leak and bacteria being spread into body or blood - Cancer - Abd surgery - Abd radiation Large bowel obstruction: findings/ diagnostics - Solution - Abd distention - N/V - Crampy abd pain - abrupt inset symptoms - chronic constipation - guarding and rigidity on abd exam - xr chest upright: free air means perforation and ileus rather than obstruction - CT abd: test of choice. Can distinguish between complete and partial obstruction, ileus, and small bowel Large bowel obstruction: management - Solution Fluid resuscitation AB's NG for vomiting Surgery. Surgical emergency for closed loop obstruction, bowel ischemia, volvulus Mesenteric ischemia: what, etiology - Solution Not enough O2 and nutrients to intestine, due to thrombus or no physical occlusion - Acute arterial occlusion, from embolism or thrombus (older than 60) - mesenteric venous thrombosis (younger than 50) - Non-occlusiev (CHF, aortic stenosis, shock) Mesenteric ischemia: findings/ diagnostics - Solution - severe cramping and abd pain - possible rectal bleeding - Hypotension/ abd distention with infarction Leukocytosis Lactic acidosis (with infarction) Duplex US: bowel spasm and fluid filled intestinal lumen CT angio: emboli, thrombus CT abd: acute mesenteric ischemia Mesenteric ischemia: management - Solution Occlusive: NPO Embolectomy Fluids TPN Non-occlusive: Correct hypovolemia Treat underlying cause Vasopressors: dopamine, dobutamine NG AB for peritonitis Pain control Esophageal varices: what, etiology - Solution Submucosal veins that can results in GI bleeding when rupturing. 60% mortality. - Cirrhosis - Portal hypertension - aspirin / NSAID Esophageal varices: Findings/ diagnostics - Solution Hematemesis melena abd pain Hypovolemic shock Gold standard: EGD CBC: hgb wnl then low because volume resuscitation prolonged PT and PTT Hypokalemia Hyponatremia Hyperglycemia Lactic acidosis Esophageal varices: management - Solution - LR/ NS till blood transfusion - Blood transfusion - NPO - Octreotide, bolus then continuous - Emergent endoscopy Prevention of re-bleeding: - Follow up endoscopy (screening endoscopy when cirrhosis) - TIPS (stent) Upper GI bleed: what, etiology - Solution Bleed between upper esophagus and duodenum Peptic ulcer disease esophageal varices Cancer Upper GI bleed: findings/ diagnostics - Solution - Abd pain - Hematemesis - melena - Hypovolemic shock - pale - bloody NG aspirate - low Hgb, though not clear representation - Endoscopy: Procedure of choice for diagnosis of duodenal and gastric ulcer. Can stop bleeding ulcer, can detect H. Pylori, and inflammatory disorders, and can perform electrocautery H. Pylori testing - Solution Detection of H. Pylori: - Endoscopic biopsy (gold standard) - urea breath test (pos is H. Pylori) - PPI can cause false negative - serum H. Pylori antibody test (can also mean previous infection) - fecal antigen H. Pylori (can assess if treatment was successful) Complications of PUD - Solution - GI bleeding Symptoms: hematesis, melena, coffee ground hematesis, pallor, tachy, hypotension, low Hct, BUN up Perform endoscopy Treat: IV fluids, blood transfusion, H2 blockers (pepcid), no vasopressin or octreotide - Perforation Symptoms: severe abd pain, epigastric pain radiating to back, boardlike abd, absent bowel sounds, knee to chest, fever, leukocytosis, free air on xr, barium studies Treat: surgery, watch poor candidates on ab's, iv fluids, and NG. - Gastric Outlet obstruction Symptoms: early satiety, n/v, epigastric pain unrelieved by food/antacids, succussion splash, NG foulsmelling large amount Perform upper GI endoscopy and saline test at 72hrs (check residual) Treat: Treat hypokalemia, if present because of N/V, Start H2 blocker (pepcid), surgery Meds used for PUD - Solution - H2 blocker (Famotidine, Ranitidine), decreases acid secretion, symptom relief in 2 wks, healing in 6wks for duodenal and 8 wks for gastric (Cimetidine raises theophylline and warfarin levels) - PPIs (Omeprazole (gastric), Pantoprazole (duodenal), Esomeprazole (gastric), suppresses gastric acid secretion. For duodenal ulcers, esophagitis, GERD. Check gastrin after 6mo and may cause low Vit B12, Ca, low iron and C Diff, hip #, pneumonia - Sucralfate. Mucosal defense enhancer. Can cause constipation. Needs acidic environment, so do not combine with H2 blocker or PPI and binds with meds, so 2hrs apart. - Cytotec. Used for ulcer prevention when on NSAID. Can cause diarrhea. Can cause contractions/ abortion. - Antacids. Supplement other antiulcer meds. Can cause diarrhea, hypermagnesemia, hypophosphatemia H. pylori treatment - Solution PPI (BID) + 2 of the following antibiotics --Clarithromycin --Metronidazole (when allergic to pcn) --Amoxicillin Antiulcer treatment for 3-7 wks: Duodenal ulcer: Omeprazole - 7 wks H2 blocker: 6-8 wks GERD (gastroesophageal reflux disease): what, etiology - Solution Chronic condition in which gastric contents enter and stay in lower esophagus because of impaired esophageal function. May cause reflux esophagitis. - Due to hiatal hernia, gastroparesis, gastric outlet obstruction - diet: caffeine, citrus, spicy, large meals, fatty meals, onions, mint, alcohol, lying down after eating - anxiety - pregnancy - smoking - meds (aspirin, NSAIDS, CCB, antihistamines) GERD findings/ diagnostics - Solution Hallmark: heartburn (after eating, supine, bending) Regurgitation Hypersalivation Dysphagia Belching Pneumonia, chest pain, cough, hoarse, sore throat -Clinical history -24-hr ambulatory PH monitoring (most specific and sensitive): gold standard. Electrode PH probe aboev LES -Barium swallow test (as screening tool and rule out inflammation, ulcers, and strictures) -Endoscopy (for diagnosis and possible biopsy and dilation of stricture) -Bernstein test (infusion of acid and ns) GERD management - Solution Phase 1: Elevate head No exercise before bed No large meals before bed Avoid chocolate, fats, alcohol, mint, spicy, citrus, coffee, tomato juice Reduce weight Stop smoking Avoid aggravating meds Use antacids PRN (after meals and bedtime) and over the counter H2 blocker (ranitidine/ famotidine) for 8 - 10 wks Phase 2: Continue phase 1. weight loss No supine No eating before bed Phase 3 (start after 2 -4 wks of other phases and no improvement): Increase dose of initial drug Start longterm daily PPI If worse: add lifestyle changes then add drug If better: remove drug Phase 4: surgery (reflux related pulm disease, ulcerative esophagitis, esophageal strictures, hiatal herna) Diverticulitis: what and etiology - Solution Perforation of colonic diverticulum (micro or macro with peritonitis) Common in people older than 50yrs (50%) First line: oral sulfasalazine. Start at 500mg/ day then increase to 4-6gm/ day. Give Folate with it. Give corticosteroid if no improvement in 2-3 wks (hydrocortisone enema) If that fails: give oral prednisone/ methylprednisone. INfliximab for pt's refractory to that Severe: hospitalize NPO no opioids/ anticholinergics nlood transfusion if needed 7-10 days corticosteroid IV (methylprednisolone) Infliximab Immunomodulators: purinethol, imuran, cyclosporine (maintenance of remission) If refractory: colectomy Toxic megacolon: surgical decompression, ab's, colectomy Surgery for: toxic megacolon refractory disease perforation hemorrhage carcinoma Toxic megacolon: symptoms and treatment - Solution Symptoms: rapid UC progression fever anemia xr abd to detect megacolon ab's (cover gram - and aneorobes) NG surgery within 72hrs if failing to respond to tx Crohn's Disease - Solution Inflammation and ulceration, stricturing, fistula, abscess across entire colon. May cause chronic inflammation, intestinal obstruction, fistula, abscess. At greater risk for developing colon ca, lymphoma, and small bowel adenoca. IBD Crohn's treatment - drugs - Solution Drugs: - Mesalamine 2.4 - 4.8gr/ day - Corticosteroids for active disease (prednisone/ methylprednisone, long course and taper - Immunomodulating drugs: azathioprine, methrotrexate if no response to corticosteroid - Anti-tumor necrosis factor therapy: infliximab, certolizumab for refractory Crohn's treatment - Solution Mild/ moderate: First line: oral mesalamine or Pentasa If not responding: Flagyl May give Cipro May give oral budesonide as first line Moderate/ severe: Corticosteroid (prednisone 40 - 60mg) until symptoms resolve Anti TNF therapy: infliximab if refractory to corticosteroid Severe/ sudden: Surgery if no response to oral corticosteroid and anti TNF therapy and suspicion for mass, obstruction, abscess. IV corticosteroids IV cyclosporine/ methotrexate (immunomodulator) Maintenance: no corticosteroid Azathioprine (2-3mg/kg/day) or inflixinab (immunomodulator and anti TNF monocloiinal antibody) Diet: well-balanced, may need supplemental enteral therapy during active disease IBD drugs: - Solution Aminosalicylates: Sulfasalazine, non sulfa: mesalamine. For induction and maintenance of remission. May cause N/V and folate malabsorption. Give folate! Corticosteroids: Prednisone, Budesonide, Methylprednisone Suppress acute flares, no maintenance May cause N/V, gastritis, adrenal suppression, osteoporosis Immunomodulators: 6-mercaptopurine, Azathioprine, Methotrexate, Cyclosporine, Tacromilus For maintenance, steroid sparing effect May cause pancreatitis, bone marrow suppression, hepatotoxicity Anti TNF Monoclonal antibodies Infliximab, certolizumab Only for Crohn's. May cause infusion related reactions: fever, pruritis, chest pain, hypotension, htn, infections/ sepsis. Expensive! Peritonitis: what and etiology - Solution Acute inflammation of peritoneum Primary: spontaneous bacterial peritonitis of ascitic fluid as complication of cirrhotic ascites. Secondary: peritonitis with cause that can be operated on, such as infection, abdominal trauma, perforation from appendicitis, colitis, PUD, diverticulitis, pancreatitis, cholecystitis. Peritonitis findings and diagnostics - Solution Primary: fever and abd pain with mental status change due to hepatic encephalopathy Secondary: acute abd pain fever n/v constipation abd distention, rebound tenderness, rigidity, decreased bowel sounds, hyper resonance on percussion ascites dyspnea/ tachypnea dehydration Primary diagnostics: ascitic fluid: protein less than 1